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Spontaneous Pneumothorax

Spontaneous pneumothorax (SP) describes a condition in which air leaks into the pleural space.


Presentation

PSP typically manifests in young men who are tall, thin, and likely to be smokers [9]. This subtype occurs in ages of 20 to 30 years. However, SSP develops in individuals aged 60 to 65 who exhibit underlying disease.

The presentation typically consists of a sudden onset of sharp pleuritic pain, which may radiate to the neck, shoulder, or abdomen. The pain subsides within 24 hours [10] as the lung adapts by slowly re-inflating.

The features are varied as some patients have mild dyspnea while others develop sequelae such as shock and possibly death. Factors that determine the severity include the amount of air that enters the pleural space, the percentage of lung collapse, and the baseline lung function.

Physical exam

Clinical findings that reflect a large pneumothorax include decreased or absent breath sounds, less movement of the chest wall, tympanic percussion, and reduced tactile fremitus [11]. Additionally, reflex tachycardia is common.

Tall Stature
  • Tall stature and low body mass index are also associated with higher rates of PSP. It is hypothesised that the RB develops in smokers and leads to the development of ELC in patients predisposed to this process.[karger.com]
Wound Infection
  • Reported measures were operative mortality, mean operation time, post-operative bleeding, persistent air leaks, chest drain duration, pain levels, pneumonia, respiratory failure, wound infection, pulmonary function, re-exploration for bleeding and air[ncbi.nlm.nih.gov]
Marfanoid Habitus
  • On physical examination he presented with marfanoid habitus. Pneumothorax was managed conservatively with resolution.[ncbi.nlm.nih.gov]
Dyspnea
  • Case 1, a 43-year old man was admitted to our hospital with dyspnea 10 days before admission. He denied any recent trauma or previous treatment for lung tuberculosis.[ncbi.nlm.nih.gov]
  • A 70-year-old man with a history of esophagectomy presented with dyspnea. A chest roentgenogram revealed a bilateral pneumothorax and bilateral chest drainage procedures were performed.[ncbi.nlm.nih.gov]
  • A 17-year-old man with a history of Nuss operation complained chest pain and dyspnea. A chest roentgenogram demonstrated a tiny bilateral pneumothorax and two metallic bars inserted at the Nuss procedure.[ncbi.nlm.nih.gov]
  • Pulmonary affection usually starts with unspecific symptoms such as cough, dyspnea, hemoptysis, and pleuritis. Pulmonary nodules are 1 of the most common manifestations. The prevalence of pleural affection is 10 to 20%.[ncbi.nlm.nih.gov]
  • BACKGROUND: Patients with primary spontaneous pneumothorax (PSP) usually complain of sudden-onset dyspnea and pleuritic chest pain. However, asymptomatic PSP has been incidentally detected on chest X-rays.[ncbi.nlm.nih.gov]
Hyperresonance
  • […] symptoms (e.g. general malaise, fatigue) are less commonly observed Signs General appearances may be normal Sweating, tachypnoea, tachycardia (most common finding) Splinting of the chest wall to relieve pleuritic pain Decreased or absent breath sounds Hyperresonance[rch.org.au]
  • Tachycardia is the most common finding and, depending on the amount of lung involved, other physical findings include decreased chest wall movement, a hyperresonant percussion note, diminished fremitus and diminished or decreased breath sounds.[aafp.org]
  • There is hyperresonance (higher pitched sounds than normal) with percussion of the chest wall which is suggestive of pneumothorax diagnosis. Chest x- rays will then be used to confirm the diagnosis of the pneumothorax.[physio-pedia.com]
Pleuritic Pain
  • The presentation typically consists of a sudden onset of sharp pleuritic pain, which may radiate to the neck, shoulder, or abdomen. The pain subsides within 24 hours as the lung adapts by slowly re-inflating.[symptoma.com]
  • pain Decreased or absent breath sounds Hyperresonance on percussion Asymmetric lung expansion, mediastinal and tracheal shift with large pneumothorax Signs of tension pneumothorax Deviation of the trachea to the contralateral side, tachycardia, hypotension[rch.org.au]
  • However, during the administration of the third cycle of Ifosfamide, he developed tachypnea, pleuritic pain in the chest, and tachycardia and was recovered to other hospital for the treatment of acute respiratory failure.[jtd.amegroups.com]
Pulmonary Disorder
  • Pneumothorax can also occur secondary to a variety of pulmonary disorders such as chronic obstructive pulmonary disease (COPD), pneumoconiosis, diffuse interstitial fibrosis, and infection diseases.[jtd.amegroups.com]
Chest Pain
  • CASE REPORT: A patient presented in the emergency setting with acute chest pain and shortness of breath caused by a tension pneumothorax.[ncbi.nlm.nih.gov]
  • Dyspnea and chest pain suddenly appear during successful chemotherapy for metastatic chemosensitive tumors should alert the physician to the possibility of SP. The treatment is directed toward lung re-expansion.[ncbi.nlm.nih.gov]
  • Abstract A 25-year-old man with a history of Marfan syndrome, asthma and smoking presented with worsening dyspnoea and right-sided chest pain worsened with deep breathing after a fall 2 days prior.[ncbi.nlm.nih.gov]
  • A 17-year-old man with a history of Nuss operation complained chest pain and dyspnea. A chest roentgenogram demonstrated a tiny bilateral pneumothorax and two metallic bars inserted at the Nuss procedure.[ncbi.nlm.nih.gov]
  • BACKGROUND: Patients with primary spontaneous pneumothorax (PSP) usually complain of sudden-onset dyspnea and pleuritic chest pain. However, asymptomatic PSP has been incidentally detected on chest X-rays.[ncbi.nlm.nih.gov]
Cyanosis
  • CONCLUSIONS: The most severe forms of pulmonary alveolar proteinosis, in which hypoxemia and cyanosis occur, have a high mortality risk during anaesthesia and whole lung lavage.[ncbi.nlm.nih.gov]
  • […] persons artificial pneumothorax aspiration of air atelectasis barometric pressure bleeding breath sounds Bronchoscopic examination bullae cent chemical pleuritis chest wall clavicles collapsed lung condition of lungs Constitutional symptoms coughing cyanosis[books.google.com]
  • Rapidly evolving hypotension, tachypnea, tachycardia and cyanosis should raise the suspicion of tension pneumothorax, which is, however, extremely rare in PSP.[err.ersjournals.com]
  • Decreased or absent breath sounds Hyperresonance on percussion Asymmetric lung expansion, mediastinal and tracheal shift with large pneumothorax Signs of tension pneumothorax Deviation of the trachea to the contralateral side, tachycardia, hypotension, cyanosis[rch.org.au]
  • Cyanosis or blueness of the skin will occur as the tissues lose their oxygen. Decreased levels of consciousness may occur because of the low blood pressure , decreased brain perfusion, and low oxygenation.[emedicinehealth.com]

Workup

The clinical assessment consists of the patient's history, the physical exam, and the appropriate tests. A large pneumothorax is diagnosed based on the exam findings.

Imaging

A pneumothorax on a chest radiograph is depicted as a collection of air as the collapsed lung is portrayed by a thin line demarcating the pleural edge. Specifically, the upright posteroanterior angle can confirm and accurately determine the size of the pneumothorax [12].

A computed tomography (CT) scan is obtained if the diagnosis is inconclusive. This modality can detect a small pneumothorax and differentiate this from other lung pathologies. CT studies can also be used to monitor the management and progress of these patients.

Pericardial Effusion
  • Abstract Alternating or phasic ECG voltage changes are most commonly associated with intrinsic myocardial electrophysiological perturbations or mechanical oscillation within a pericardial effusion.[ncbi.nlm.nih.gov]
Right Axis Deviation
  • When an ECG has the arm leads incorrectly placed, the ECG will display right axis deviation and inversion of the P waves in lead I.[ncbi.nlm.nih.gov]
T Wave Inversion
  • These findings include axis deviation, T-wave inversion, and right bundle branch block. When an ECG has the arm leads incorrectly placed, the ECG will display right axis deviation and inversion of the P waves in lead I.[ncbi.nlm.nih.gov]
Inverted P Wave
  • An ECG was administered; findings indicated reversal of the arm leads (right axis deviation and inverted P waves in lead I), but there was no actual limb lead reversal present. ECG findings resolved upon resolution of the pneumothorax.[ncbi.nlm.nih.gov]
Inverted P Wave
  • An ECG was administered; findings indicated reversal of the arm leads (right axis deviation and inverted P waves in lead I), but there was no actual limb lead reversal present. ECG findings resolved upon resolution of the pneumothorax.[ncbi.nlm.nih.gov]

Treatment

The treatment of a pneumothorax will depend on the cardiorespiratory status, the severity of the symptoms, and the size of the defect [13] [14]. Mild cases of PSP and SSP are managed through observation while large ones require aspiration or insertion of a chest tube [15]. The latter is indicated if catheter aspiration fails to remove the air or in cases of SSP.

Some patients will warrant surgery, in which a thoracoscope is placed into the pleural space. These individuals will also need high flow oxygen.

Prognosis

Uncomplicated cases do not require treatment and will usually resolve in about 10 days. Recurrences occur especially in smokers and those with COPD or AIDS.

Etiology

PSP is very likely caused by a ruptured subpleural bleb or bulla [1] [2] whereas SSP develops in those with underlying lung disease such as chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), infections, congenital disorders, or lung cancer [3] [4].

There may be a genetic component as well. For example, Marfan syndrome, Birt-Hogg-Dube (BHD) syndrome, and homocystinuria have been associated with PSP.

Smoking is a major risk factor as it may elevate the risk by 9 -fold [5].

Epidemiology

The incidence of first -time spontaneous pneumothorax in men is 7.4 to 18 patients per a population of 100,000 and in women is 1.2 to 6 per 100,000 [6]. With regards to SSP, the incidence in men is 6.3 cases per 100,000 individuals and in women is 2 cases per 100,000 [7].

Sex distribution
Age distribution

Pathophysiology

Normally, the pressure in the pleural space is negative due to the outward expansion of the chest wall and the intrinsic elastic recoil. Therefore, the chest has a tendency to collapse inward. Hence, when air enters this pleural space, the pressure increases while the vital capacity decreases. Additionally, there is an inverse relationship between the size of the pneumothorax and the volume of the lung. When the former expands, the latter becomes smaller.

The pathogenesis is not uniform in all individuals and has not been established with regards to how ruptured blebs or bullae could cause air to enter the pleural space [8].

Prevention

Since some patients may experience recurrence. Preventive measures such as surgery may be beneficial in these patients. Surgery involves repairing the weak sites of the lung and strengthening the pleural layers by suturing them to each other.

Summary

Spontaneous pneumothorax (SP) refers to the presence of air in the pleural space. It may occur as a primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP) due to different etiologies. The diagnosis is made clinically with the help of imaging. Management of this condition depends on numerous factors.

Patient Information

What is a spontaneous pneumothorax?

This is a condition in which air enters the space between the chest wall and the lung. It may occur spontaneously, or secondary to lung diseases. Smoking increases the likelihood of developing this especially in individuals in their 20s and 30s.

What are the symptoms?

How is it diagnosed?

The clinician will ask the appropriate questions, perform a physical exam and order imaging tests such as chest x-ray and possibly a CT scan.

How is it treated?

Mild cases can be observed without any active treatment . Severe cases will require drainage of the air by either aspiration or insertion of a chest tube.

References

Article

  1. Abdala OA, Levy RR, Bibiloni RH, Viso HD, De Souza M, Satler VH. Advantages of video assisted thoracic surgery in the treatment of spontaneous pneumothorax. Medicina (B Aires). 2001; 61(2):157-60. Spanish.
  2. Chen YJ, Luh SP, Hsu KY, Chen CR, Tsao TC, Chen JY. Video-assisted thoracoscopic surgery (VATS) for bilateral primary spontaneous pneumothorax. Journal of Zhejiang University Science B. 2008; 9(4):335-40.
  3. Luh SP, Tsai TP, Chou MC, Yang PC, Lee CJ. Video-assisted thoracic surgery for spontaneous pneumothorax: outcome of 189 cases. International Surgery. 2004; 89(4):185-9.
  4. Wallach SL. Spontaneous pneumothorax. New England Journal of Medicine. 2000; 343(4): 300; author reply 300-1.
  5. Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest. 1987; 92(6):1009-12.
  6. Melton LJ 3rd, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. American Review of Respiratory Disease. 1979; 120(6):1379-82.
  7. Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Thorax. 2000; 55(8):666-71.
  8. Noppen M. Do Blebs Cause Primary Spontaneous Pneumothorax?: Con: Blebs are not the cause of primary spontaneous pneumothorax. Journal of Bronchology. 2002; 9(4):319–325.
  9. Weissberg D, Refaely Y. Pneumothorax: experience with 1,199 patients. Chest. 2000; 117(5):1279-85.
  10. Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008; 76(2):121-7.
  11. Shields TW, Locicero J, Ponn RB, et al. General Thoracic Surgery. New York: Lippincott Williams & Wilkins; 2005.
  12. Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraete A; Vlaamse Werkgroep voor Medische Thoracoscopie en Interventionele Bronchoscopie. Quantification of the size of primary spontaneous pneumothorax: accuracy of the Light index. Respiration. 2001; 68(4):396-9.
  13. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001; 119(2):590-602.
  14. MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010; Thorax. 201; 65 (Suppl 2):ii18-31.
  15. Archer GJ, Hamilton AA, Upadhyay R, Finlay M, Grace PM. Results of simple aspiration of pneumothoraces. British Journal of Diseases of the Chest. 1985; 79(2):177-82.

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Last updated: 2018-06-21 23:01